Provider Demographics
NPI:1922071422
Name:NYSTROM, EVA (FNP-BC)
Entity Type:Individual
Prefix:
First Name:EVA
Middle Name:
Last Name:NYSTROM
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 728
Mailing Address - Street 2:
Mailing Address - City:CAMAS
Mailing Address - State:WA
Mailing Address - Zip Code:98607-0728
Mailing Address - Country:US
Mailing Address - Phone:360-980-2441
Mailing Address - Fax:877-491-4990
Practice Address - Street 1:415 SE 177TH AVE
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98683-4201
Practice Address - Country:US
Practice Address - Phone:360-980-2441
Practice Address - Fax:877-491-4990
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-07
Last Update Date:2022-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP30004316363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA9642158Medicaid
WAP09138Medicare UPIN
WA9642158Medicaid